Decoding open defecation: Relevance of early findings for field and policy

In my previous blog, I described the prevalence and predicaments of open defecation (OD) in India. For my PhD thesis, I am working with GDS to make villages open defecation free (ODF) by investing in construction of toilets as well as bringing about a behavior change and estimating the impact on the adoption of toilets, child health and basic sanitation practices. Our recently completed census baseline survey gives us imperative insights to do the same.

In this blog, I’ll share early findings from these field interventions and discuss how these insights help us to analyze existing and prevalent public policies.

Lack of toilets or behavior change? Or both?

Nearly 95% of the households in our survey do not own a toilet and only 4% use a community toilet. Government interventions are yet to reach Eastern U.P. When asked “Why do you go out for OD?”,* a staggering 48.90% of the respondents (representative women of the households) acknowledge the practice of OD as “tradition or habit or have always done so”, essentially revealing a preference for open defecation. Following closely, 48.71% of the respondents identify the lack of toilets as their reason for OD. This result makes a strong case for an intervention that incorporates both behavior change and toilet construction. This means that we are on the right track!

[*Note: “Why do you go out for OD?” was a multi-response question and the enumerators were trained not to prompt the respondents.]

Proud owners of toilets. Only 5% of the households in our project area own a toilet. (Photo credit: Payal Seth)

Handwashing

Bacterial and viral contamination, resulting in anemia, diarrheal disease, and acute respiratory infection, end the lives of nearly three million children per year and contribute to the severe stunting of millions more. Handwashing with soap is widely regarded as “the most cost-effective vaccine” against such deaths (World Bank 2005), as it decreases person-to-person transmission and protects the last point of contact between the body and germs (WHO 2009). Unfortunately, however, only 10% of our respondents wash their hands with soap after defecating. Because our intervention includes awareness-raising and training with regards to handwashing practices, this finding affirms our approach and raises our confidence that the intervention design may make a significant difference in the health and nutrition of the people.

A training session in practice: A representative woman or man from each household in the intervention village was trained on how to use the soap and pour water. They were encouraged to practice this handwashing technique at critical moments in the fecal-oral transmission route. (Photo credit: Payal Seth)

Need for reassessing government policies

There is a stark digression between the current government policies and the requisite changes in the field. In fact, while addressing the group of scholar, academics, and scientists at the conference in National Institute of Agricultural Economics and Policy Research (NIAP), TCI Director Prabhu Pingali said, “a brick and mortar model of providing toilets under the government’s Swach Bharat Abhiyan (SBA)** fails to identify the root of the problem: a need for behavior change to successfully control open defecation”.

[**Note: Swachh Bharat Abhiyan (In English: Clean India Mission) is a campaign by the Government of India to reduce or eliminate open defecation through the construction of individual, cluster and community toilets by 2 October 2019, by constructing 12 million toilets in rural India, at a projected cost of ₹1.96 lakh crore (US$30 billion).]

Even though there have been attempts to include celebrities to propagate the use of toilets, SBA is heavily fixated on the provision of hardware without complementary investments in behavior change software (as Dr. Pingali rightly pointed out).

Another disturbing trend in current public policy frame is the abominable absence of handwashing messaging. There has been no broadcast that encourages handwashing, let alone the correct methodology for the same. The significance of handwashing has been unacceptably understated or completely ignored.

The experimental design for my PhD dissertation has been carefully planned to account for these gaps and to provide an alternative approach as well as robust evidence for achieving open defecation free villages and improved child nutrition. Our behavior change intervention consists of community led total sanitation (CLTS) (Click here for more details on the CLTS methodology.) along with proper training on handwashing. CLTS facilitates a community’s analysis of their own sanitation profile. Using interactive activities and thought-provoking discussion, the community reflects on their practices of defecation which leads to greater awareness of the consequences of mass open defecation. The community then becomes motivated to change, and leverages social pressure to get individuals to adopt toilet-use.

Meanwhile, our module on handwashing discusses the proper way of washing hands ― using soap instead of ash and mud, rubbing the hands with soap and then pouring water on it, repeating the process not just after defecating but also before cooking food, feeding the baby, etc.

These keen children learn the proper way of handwashing as taught by Payal Seth (author). (Photo credit: Ranjana Kumari)

Finally, I’ve seen first-hand the value of conducting a rigorous baseline study. This is of utmost importance because it helps the researcher validate the interventions in the field. It is only then that the next stage follows.

As we move ahead in our study, we are interested in understanding the returns behavior change has on the adoption of toilets and nutrition. Please look out for our new posts as we continue to analyze interesting facts from our data!